Varney’s Midwifery Notes Signs and symptoms of impending labor • Once lightening occurs- during labor your fingers will diverge rather than converge. • Lightening provides as indication of the adequacy of the pelvic inlet • Braxton Hicks begin at about 6 weeks but are not felt until much later on in pregnancy • Bloody show is the expulsion of the mucus plug that closes the cervical canal during pregnancy • If the mucus plug is not completely expelled and is protruding from the vagina, an inexperienced caregiver may mistake it for cord prolapse • Many women experience an energy spurt 24 hours before the birth of baby. Advise her to not do anything too draining as this may be a sign of labor starting soon Data Base for the Diagnosis of Labor • The uterine contractions of labor are unique as the only painful physiologic muscular contractions • If there were not rests between uterine contractions, the uterus wold probably rupture • The three stages of a contraction: increment, acme, decrement • A contraction can be felt with your hand before the mother can feel it • During a good uterine contraction the uterus cannot be digitally indented • The fundal portion of the uterus draws the lower segment up towards the top and then as the muscle fibers thicken in the fundus they begin to bear down to expel the baby • Effacement is the result of the lower segment of the uterus being lengthened • Effacement draws the cervix up into the uterus so that the cervix becomes a part of the continual birth canal • Dilation is the enlargement of the external os of the cervix • Station is the relationship of the presenting part of the fetus to an imaginary line drawn between the ischial spines (-5 is floating, +5 is in the vaginal orifice) Determining the status of the membranes • Membranes may have a high leak that stops when the baby descends • The PH of amniotic fluid is an alkaline of 7.0-7.5 • Unfortunately blood, cervical mucous and vaginal secretions are also alkaline and may invalidate tests • A specimen can be used to do a fern test but you need a microscope. (AKA, too much for a midwife, also the test may be invalid) • Digital examination for SROM is most helpful • If you cannot easy feel the bag of water bulging than you should have the woman bear down or you can do fundal pressure then you can see the membranes bulge. • Membranes that are in close contact with the head feel different from the baby’s head • Diagnosis is definitive for ruptured membranes, 1. when you see amniotic fluid pooled in the vaginal vault during an exam. 2. When you can’t feel the membranes over the presenting part Differential Diagnosis • Back pain that may be associated with a UTI may be mistaken for labor- a UTI could be suspected if other labor signs are not present • False labor can be extremely discouraging to mother- give her emotional support • Management of care of the women with false labor and the woman with the general miseries of the end of pregnancy is the same The management of false labor and early labor • Send the woman home with 2 sleeping pills, instructs her to take a soak, then drink a hot drink with wine and try to sleep, if she is not asleep in an hour she can take another sleeping pill. • It’s frequently difficult to differentiate between false labor and early labor Varney’s Midwifery Notes • A woman will cope better in her home • Walking may stimulate labor • Lots and lots and lots of rest Initial evaluation of mother and fetus in labor • Complete evaluation needs to be done once the mother is in labor • A woman in a home birth situation has probably been followed more closely and may not need such an extensive evaluation as she would by a doctor in a hospital • Evaluation should include: history, physical and pelvic exam, abdominal exam, and lab tests • Always be willing to re-evaluate with an open mind Normal first stage of labor- latent • Begins with true labor contractions that are evidenced by cervical change. • First stage of labor is divided into two phases, latent and active • The active phase is divided into acceleration, maximum slope, and deceleration • The latent phase in from the beginning of labor until dilation begins to progress actively, this is usually from the onset of contractions to 3-4 cm dilation or to the beginning of the active phase • Little to no decent occurs during latent • In latent phase contractions 10-20 min, lasting from 15-20 seconds, mild intensity increasing to occurring approximately every 5-7 minutes, lasting 30-40 sec. • Active phase is from the start of active progression to the completion of dilation, generally from 3 or 4 cm to 10 cm. • Progressive descent of baby occurs in the later part of the active phase and during second stage • The phase of the maximum slope is when the most elation occurs • In nuliparas in maximum slope dilation averages 3 cm per hour Active phase • Contractions during active phase become increasingly frequent and more intense • By the end of the active phase contractions are usually coming every 2-3 min, lasting 60 sec. • Woman may become increasingly apprehensive as she can no longer control • Deceleration phase has long been known as the transition phase • Signs during transition will probably be uber intense • Evaluation of the progress of labor is based on: effacement, dilation, station, contraction pattern (frequency, duration, and intensity), behavior changes, signs and symptoms of transition, and impending second stage Fetal normality • Determination of fetal lie, presentation, variety, and position is essential information • Variety is the same chosen point on the fetus used in defining position, in relation to the anterior, transverse, and posterior of the mom’s pelvis • Transverse and oblique lies are abnormal- may require c-section • Approximately .5% enter labor with a shoulder presentation • 95% of longitudinal lies are vertex, cephalic presentation- of these, approx. 2/3rds are positioned with the occupy on the left side • The most common position at the onset of labor is LOT • Approximately 3%-3.5% of women enter labor with a Breech presentation and 5% with a face presentation • After 32 weeks the combination of fetal growth and the decrease in amniotic fluid causes the fetus to be constrained by the uterine walls • Vaginal exams can be very helpful in determining positions, using the presenting part, feeling for suture lines or other fetal extremities Varney’s Midwifery Notes Adaptation to the Pelvis • Vaginal exams during labor provide information regarding the adaptation of the fetus to the pelvis, specifically synclitism or asynclitism • Molding and caput result from pressure on the fetal head by the maternal structures of the birth canal • Molding is the change in the shape of the head as a result of the soft skull overlapping each other cause the bones have not yet fully formed • Caput is the formation of edematous swelling over the most dependent part of the presenting head • A cephalhematoma does not cross over suture lines whereas caput crosses suture lines as a general swelling Fetal Heart Tones • Evaluation of the fetal heart is based on a combination of rate and pattern- pattern is most significant when there is a deviation from normal • Changes in the FHT that are associated with uterine contractions are called periodic fetal heart rate changes • In order for a change in heart rate to be considered baseline (or a new normal), it must be consistent at that number for at least 10 minutes • Methods of evaluation: fetoscope, external fetal monitor, internal fetal monitor • In order to get an accurate picture of FHT, midwife must listen to them between and during contractions. Also, be sure to listen for a full 60 seconds to get an accurate count Maternal Physiological Changes • Blood pressure rises during contractions with the systolic rising an average of 15, and diastolic rising an average of 5-10 • Between contractions the BP should return to pre-labor levels • A shift of the woman from a supine position to a lateral position eliminates the change in BP • The increased metabolic activity is reflected by an increase in body temp, pulse, respirations, cardiac out put, and fluid loss • Temperature is slightly elevated during labor • Normal temp elevation should not exceed 1-2 degrees F. • Changes for mom vary greatly is she is in a lateral vs, supine position • Slight proteinuria is common in a 1/3rd to 1/2 of all women in labor • Digestion motility is drastically slowed down during labor, liquids are not effected • Blood coagulation time decreases and there is a further increase in plasma fibrinogen during labor • WBC increases throughout the first stage of labor by about 5,000, to an average of about 15,000 • Blood sugar drops during labor, especially during difficult labors, most likely as a result of the increase in activity of the uterine and skeletal Management Plan for the Normal First Stage • In home birth setting, the word “admission” takes on a different meaning: rather than the woman being admitted, she admits you into her environment. • Enemas should be carefully thought through before they are used • Perineal shave should be the woman’s choice- cleanliness is a matter of washing and drying • Fasting increases the concentration of hydrochloric which is the dangerous substance in aspirate • Woman have more energy and are better hydrated when they have eaten • The woman should be free to move to positions that are comfortable for her • If the baby is in a transverse or breech, varied positions are beneficial Varney’s Midwifery Notes • The woman should be allowed to walk around as much as she wants unless there are serious risks that would risk walking out • Factors affecting medication decisions: mother’s desire for medication, labor status, fetal size, fetal condition, maternal size, mother’s emotional state or need for medication.